Step-2

1

Contact Information  

2

Patient Assessment Questions

3

Patient Risk Factors

4

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2. Patient Assessment Questions


Date of Birth


Leg pain, aching or cramping

No

Yes


Burning or itching of the skin

No

Yes


“Heavy” feeling in legs

No

Yes


Visible varicose or spider veins

No

Yes


Leg or ankle swelling, especially at the end of the day

No

Yes


Skin discoloration or texture changes, such as above the inner ankle

No

Yes



No

Yes


Restless Leg Syndrome

No

Yes